Attachment G (Third-Party).pdf
PDF 255 KB Posted
- Attached to
- ON CALL DECK REPAIR SPARTANBURG
- Solicitation number
- 5400029930
- Issued by
- Spartanburg County, South Carolina
About this file
This is a Damage Claim Form for third-party claims issued by the South Carolina Department of Transportation. The form is designed to document and process claims for vehicle damage or personal injury resulting from incidents involving SCDOT operations or vehicles. Claimants must complete all applicable fields on the form and provide supporting documentation, including repair estimates or paid invoices to substantiate claimed amounts. The form requires claimant identification and contact information, including name, Federal Employer Identification Number or Social Security Number, mailing address, phone number, and email address. Additionally, details regarding the damaged vehicle must be provided, including vehicle make, model, year, license plate number, and state registration information.
All required fields on the form must be completed and claimant signatures must be properly notarized to ensure validity of the claim submission. Supporting documentation such as repair estimates or invoices is mandatory for claims involving vehicle damage, personal injury, or non-vehicle-related damage. The form serves as the official instrument through which third parties seek reimbursement from SCDOT for damages arising from departmental operations or vehicle involvement.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment H Work Zone.pdf | ||
| AMENDMENT 1.pdf | ||
| SOLICITATION.pdf | ||
| Attachment D.pdf | ||
| Attachment E.pdf | ||
| Attachment F.pdf |
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Text version
Attachment G - Damage Claim Form (Third-Party)
FC11!12062
R8V011ZJIA
SOUTH CAROLINA DEPARTMENT OF TRANSPORTATION
DAMAGE CLAIM FORM
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AFADAVIT
COUNTY OF STATE OF
Personally ,1ppe.all!d � me , who, upon o.ath, s,ays th.at the .above aatnant(I) Nne claim is true .and jU5t, .and th.at he/she hzi not ..-eceived compensation from other sources for dam.ages cl.aimed.
Sworn to before me this day of 20_
NolaryP!dctt>r (SUie) Prfnll!d name<•I or e1am;inq,1
PmteCI nne « IIOlaly Slgllallln!(&J (lJ Cililnln(&J
My 0111MC5&1on l!llplre&
DO NOTWRITE BELOW THIS UNE. FOR ICDOT USE ONLY.
Olller111i11'NSilMllved
� -- Amounl$ Claim� DaRNMBlatsa>ar Sa>oTff.-ltitille DisappnNed Dale
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